Requesting Plan G Coverage for Your Patient

Plan G Drugs that Require Special Authority Approval

For a list of Plan G drugs that require Special Authority approval, please see the Special Authority Drug List. Plan G drugs are indicated as "LCD—Psychiatric Medications Plan" in the Special Authority Category column.

Plan G Regular Benefits

Important Notes

PharmaCare Plan G may not cover all available formulations and strengths of the drugs listed below.

examples of drug formulation include tablet, capsule, liquid, and injection

examples of drug strength include 5 mg and 10 mg/ml

If PharmaCare covers a generic version of a drug, PharmaCare generally covers only part of the cost of the brand product. Some generic versions may not be covered under the Low Cost Alternative Program.

This list is intended as a general reference only of the products covered by Plan G. It may not reflect the most recent changes to the formulary.

PharmaCare formularies are not a replacement for professional medical judgment and advice.

Generic Drug Name

Brand Drug Name

alprazolam

Xanax ®

amantadine

Symmetrel ®

amitriptyline

Elavil ®

amitriptyline hydrochloride

PMS-Amitriptyline

atenolol

Tenormin ®

benztropine

Bensylate ®

bromazepam

Lectopam ®

bromocriptine

Parlodel ®

buprenorphine/naloxone

Suboxone ®

busiprone

Buspar ®

carbamazepine

Tegretol ®

chloral hydrate

Noctec ®

chlordiazepoxide

Librium ®

chlorpromazine

Largactil ®

citalopram

Celexa ®

clomipramine

Anafranil ®

clonazepam

Rivotril ®

clonidine

Catapres ®

clonidine

Dixarit ®

clorazepate

Tranxene ®

clozapine

Clozaril ®

desipramine

Norpramin ®

dextroamphetamine

Dexedrine ®

diazepam

Valium ®

diazepam

Vivol ®

diphenhydramine injection

diphenhydramine injection USP

disulfiram

Antabuse ®

divalproex

Epival ®

doxepin

Sinequan ®

droperidol

Inapsine ®

escitalopram

Cipralex ®

fluoxetine

FXT 40 ®

fluoxetine

Prozac ®

flupenthixol

Fluanxol ®

flupenthixol decanoate

Fluanxol Depot ®

fluphenazine

Moditen ®

fluphenazine decanoate

Modecate Concentrate ®

fluphenazine decanoate

Modecate Injection ®

flurazepam

Dalmane ®

fluvoxamine

Luvox ®

imipramine

Impril ®

imipramine

Tofranil ®

levodopa / carbidopa combination tablet

Sinemet ®

levothyroxine

Eltroxin ®

levothyroxine

Synthroid ®

liothyronine

Cytomel ®

lithium carbonate

Carbolith ®

lithium carbonate

Duralith ®

lithium carbonate

Lithane ®

lorazepam

Ativan ®

loxapine

Loxapac ®

maprotiline

Ludiomil ®

methadone

Methadose ™

methotrimeprazine

Nozinan ®

methylphenidate

Ritalin ®

mirtazapine

Remeron ®

moclobemide

Manerix ®

morphine (24-hour slow-release)

Kadian ®

nitrazapam

Mogadon ®

nortriptyline

Aventyl ®

oxazepam

Serax ®

paliperidone

Invega ®

paroxetine

Paxil ®

pericyazine

Neuleptil ®

perphenazine

Trilafon ®

phenelzine

Nardil ®

pimozide

Orap ®

pindolol

Visken ®

pipotiazine

Piportil-L4 Injection ®

procyclidine

Kemadrin ®

propranolol

Inderal ®

quetiapine

Seroquel ®

risperidone

Risperdal ®

sertraline

Zoloft ®

temazepam

Restoril ®

tetrabenazine

Nitoman ®

thiothixene

Navane ®

tranylcypromine

Parnate ®

trazodone

Desyrel ®

triazolam

Halcion ®

trifluoperazine

Stelazine ®

trihexyphenidyl

Artane ®

trimipramine

Surmontil ®

tryptophan

Tryptan ®

valproic acid

Depakene ®

venlafaxine

Effexor ®

yohimbine

Yocan ®

zuclopenthixol

Clopixol ®

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